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PATIENT IDENTITY
Name Age Gender Medical record Date of admission : Mr. L.H.B : 71 years old : Male : 568120 : 13 th September 2012
HISTORY TAKING
Chief complaint: Chest pain Guided anamnesis: Occured since 4 days ago, getting worse 1 day before admission. The patient complain of pain on the left side of chest, non radiated The pain felt like pin and needle feeling. Intermittent pain, frequency of recurrent attack > 5 times a day with increasing intensity, duration about 5-10 minutes. The pain doesnt triggered by activity and not relieved by resting. DOE (+) arises especially when chest pain relapse. Nausea (-), Vomiting (-),PND (-), orthopneu (-).
CLINICAL EXAMINATION
GENERAL STATE Moderate illness/normoweight/conscious VITAL SIGN Blood pressure : 150/80 mmHg Pulse : 80 bpm Breathing : 22 x/minute Temperature: 36.70C
Head Examination Eyes : anemic -/-, icterus -/ Lip : cyanosis (-) Neck : lymphadenopathy (-), JVP R-2 cmH2O Chest Examination Inspection : symmetric R=L, normochest Palpation : mass (-), tenderness (-), VF R=L Percussion : sonor Auscultation : breath sound :vesicular additional sound : ronchi -/wheezing -/-
Cardiac Examination Inspection : IC wasnt visible Palpation : IC palpable Percussion : normal heart size
-Upper border -Lower border -Right border -Left border
Auscultation (-)
: left 2nd ICS : left 5th ICS : right parasternalis line : left medioclavicular line
Abdominal Examination Inspection : flat and following breath movement Auscultation : peristaltic sound (+) ,normal Palpation : liver and spleen unpalpable Percussion : tympani, ascites (-) Extremities - Oedema : pretibial -/-, dorsum pedis -/-
ELECTROCARDIOGRAM
Rhythm: sinus rhythm QRS rate: HR 69 bpm P wave : 0.06 sec PR interval: 0.12 sec QRS complex: 0.08 sec Axis: Normo axis ST segment: isoelectric T-wave inverted: I, AvL, V5, V6 Conclusion: sinus rhythm Hr= 69 bpm, lateral wall myocard ischemia
LABORATORY FINDING
Test
WBC RBC HGB HCT MCV MCH MCHC PLT
Result
7,23x103 mm3 5,35 x 106 mm3 14,5 g/dl 44,3 % 82,8 fL 27,1 pg
Normal value 4,0-10,0 x 103 mm3 4,0-6,0 x 106 mm3 13,0-17,0 g/dl 40,0-54,0 % 80-100 fL 27,0-32,0 pg 32-38 g/dL 150-500 x 103
32,7 g/dL
238 x 103 /uL
LABORATORY FINDING
Test
GDS Ureum Creatinin SGOT SGPT Total Cholesterol HDL LDL 110 20 1,0 19 11 156
Result 110
26
75
LABORATORY FINDING
Test
Trigliserida CK 51 104
Normal value
CK-MB
Troponin T Uric Acid
13
7,4
<25
F(2,4-5,7), M(3,4-7,0)
WORKING DIAGNOSIS
Unstable angina pectoris HT Grade I on treatment
THERAPY
O2 2-4 liters/minute IVFD NaCl 0,9 % 500cc/24hour Farsorbid 5 mg/SL (when chest pain occured) Farsorbid 10 mg 1-1-1 Antiplatelet: Aspilet 80 mg 1-0-0 Clopidogrel 75 mg 0-1-0 Anti Hypertension: Lisinopril 5 mg 0-0-1 Simvastatin 20 mg 0-0-2 Alprazolam 0.5mg 0-0-1 Laxadyn Syrup 0-0-2 Arixtra 2.5 mg/day/SC
DISCUSSION
CAD
CAD
ACS
UAP
NSTEMI
STEMI
DEFINITION
Angina pectoris is a syndrome characterized by chest pain resulting from an imbalance between O2 supply & demand, and is most commonly caused by the inability of atherosclerotic coronary arteries to perfuse the heart under conditions of increased myocardial O2 consumption.
CLASSIFICATION
Based on CANADIAN CARDIOVASCULAR SOCIETY FUNCTIONAL CLASSIFICATION
CLASS I No angina with ordinary activity. Angina with strenuous, rapid or prolonged exertion. CLASS II Slight limitation of ordinary activity ; angina when walking up stairs briskly, or walking on a cold or windy day. CLASS III Marked limitation ; angina when walking at normal pace up flight of stairs, or walking 1-2 blocks distance. CLASS IV Angina on minimal exertion or at rest.
UNSTABLE ANGINA
angina at rest (> 20 minutes) new-onset (< 2 months) exertional angina (at least CCSC III in severity) recent (< 2 months) acceleration of angina (increase in severity of at least one CCSC class to at least CCSC class III)
PATHOGENESIS
Plaque rupture Thrombus formation Incomplete/ intermittent occlusion of the infactrelated vessel to the presence of collateral channels/ to small size of affected vessel.
Cardiology, Desmond G. Julian, J.Campbell Cowan, James M. McLenachan, 8th edition, Elsevier, 2005
RISK FACTOR
DIAGNOSE
MANAGEMENT
stabilizing any plaques that may have ruptured in order to prevent a heart attack,
MANAGEMENT
THANK YOU